Introduction

Traumatic injuries of the spleen are either penetrating or blunt. There are grading systems based on severity and anatomy, and management in recent years has become largely nonoperative. Post-splenectomy patients have important immunocompromise issues that must be managed properly in the setting of infection.

Etiology

Traumatic injuries of the spleen are either penetrating or blunt. In children with splenic trauma, non-accidental trauma must be a consideration. Preexisting splenomegaly makes the spleen capsule weaker and easy to injure and the inferior portion of the spleen is more caudal and less protected by the ribs. In the United States, most spleen trauma is due to blunt injury, usually from motor vehicle accidents. Less frequently, spleen trauma is penetrating via a variety of mechanisms, either intentional or accidental. In penetrating trauma, the wound can be very small and still cause significant spleen trauma.

Epidemiology

Most references suggest the spleen is the most commonly injured solid organ in trauma for both blunt and penetrating mechanisms. The wound of a penetrating trauma need not be near the spleen to cause significant injury. Penetrating stab wounds made by right-handed assailants tend to enter the abdomen on the left side and are more associated with spleen injuries than if the assailant is left-handed. Other severe injuries can be associated with spleen trauma so these should be looked for during patient assessment.

Pathophysiology

Spleen trauma is graded from 1 to 5 in increasing order of severity. Grade 1 is less than 10% of surface area involved in hematoma or capsule laceration less than 1 cm. Grade 2 is hematoma 10 to 50% of surface or capsule laceration 1 to 3 cm in depth. Grade 3 is hematoma of more than 50% of the subcapsular surface area or if hematoma is known to be expanding over time, if the hematoma has ruptured, intraparenchymal hematoma either more than 5 cm or known to be expanding, or capsule laceration more than 3 cm in depth and/or involving a trabecular blood vessel. Grade 4 is laceration involving a hilar or segmental blood vessel if there is partial devascularization or if it is more than 25% of the spleen. Grade 5 is either a shattered spleen or complete devascularization of the entire spleen. These grades often guide treatment decisions, such as if observational or operative management is chosen for the spleen injury by the treating surgeon. The role of antihemorrhagic intravenous agents such as a tranexamic acid is discussed elsewhere.

Toxicokinetics

Pediatric spleen trauma management is similar to that in adults. To reduce potential care delays, the emergency care provider is advised to clarify ahead of time if there are any age cutoffs for trauma patient management in general and spleen injury cases in particular at their specific facility. Antipneumococcal vaccination typically is given around 2to 3 weeks after splenectomy to decrease the risk of catastrophic sepsis events. Historically, the organisms most feared in this setting have been Streptococcus, Neisseria meningitis, and Haemophilus influenza type B. Fortunately, as of the 2010s in the developed world, there are effective vaccines for the latter two which are usually given to children prior to entering elementary school (H. influenza) or around age 18 (N. meningitis). Anti-streptococcal vaccination is evolving, and polyvalent vaccines are becoming more used and over time have been developed against a wider spectrum of subspecies. As of 2017, a 13-valent anti-streptococcal vaccination has become available in some markets. Infectious disease issues affecting trauma patients in the developing world and of completely unimmunized patients are discussed elsewhere. The vast majority of children in developed nations (as of 2017) receive a series of polyvalent anti-streptococcal vaccinations; but to date, this has not changed the post-splenectomy vaccination recommendation. The persistence of an unimmunized minority in developed nations despite the near-unanimous recommendations of the medical community for the immunization of children will likely prevent changes in this recommendation for the foreseeable future.

History and Physical

A history of trauma to the left-upper quadrant should increase suspicion of splenic injury. The patient may exhibit Kehr sign, which is pain in the left shoulder that worsens with inspiration. Abdominal tenderness and peritoneal signs are common presentations and should warrant further assessment. Abdominal wall contusions, hematoma, and/or splenomegaly may be present. An unremarkable physical exam should not exclude splenic injury in a patient with a positive history or symptoms.

Evaluation

A FAST exam should be used in hemodynamically unstable patients to rapidly assess the degree of trauma and bleeding. It is understood in the developed world that CT scan will follow a negative FAST evaluation of a trauma patient with suspicion of intraabdominal trauma unless other operative or management priorities must be addressed first. Where CT scan is unavailable in a reasonable timeframe, such as some areas in the developing world or similar settings, diagnostic peritoneal lavage (DPL) can be considered as the next step after negative FAST. CT scan of the abdomen has traditionally been performed with oral and/or intravenous (IV) contrast to assess the degree of injury, although there has been a recent movement toward consideration of ingested contrast as no longer mandatory in the CT scanning of trauma patients with suspected intraabdominal injuries. The IV contrasted spleen is significantly different in appearance on CT than similar images obtained without IV contrast. If IV contrast is not used (as of 2017), it is understood that, even with modern multi-detector CT scanning, very significant splenic injuries could be missed by the lack of image optimization. CT findings may include hemoperitoneum, hypodensity, and contrast blush or extravasation. Contrast blush and extravasation are predicted to fail to appear in the absence of adequate IV contrast enhancement of the spleen images. Assessment of vital signs is imperative to monitor hemodynamic status. Repeat CT scans are not indicated in patients who are hemodynamically stable. Follow-up studies are indicated as needed for patients whose clinical status changes. Plain films and MRI offer limited value and are not indicated for the evaluation of splenic trauma.

Treatment / Management

Management favors nonoperative and conservative treatment in hemodynamically stable patients. Conservative measures include fluid/blood replacement as necessary with monitoring. Patients should be considered for surgical intervention if they are hemodynamically unstable, have a significant injury to other systems, or if they are currently on anticoagulant/antiplatelet therapy. Candidates for surgical intervention will undergo exploratory laparotomy for assessment, repair, or removal. Angiographic embolization also may be considered as an alternative to surgery in patients who fail nonoperative management.

Differential Diagnosis

Splenic trauma must be discovered in the undifferentiated abdominal trauma patient. The methods of discovery have evolved in the developed world over the last several decades with the advent and subsequent refinement of advanced imaging. [1]A traumatized spleen either requires operative intervention or it does not. An actively bleeding traumatized spleen is much more likely to require immediate operative intervention by laparotomy than a traumatized spleen where the bleeding remains contained within an otherwise intact splenic capsule. This seems to validate diagnostic peritoneal lavage (DPL) as a method of determining if a splenic trauma patient needs to go to the operating room or could be observed. DPL (discussed in more detail elsewhere) is now of largely historic interest, except in austere environments where advanced imaging is either impossible or prohibitively slow to obtain. [2][3]DPL has also been largely supplanted by point of care ultrasound (POCUS) utilization in the focused assessment with sonography for trauma (FAST). [4]The specifics of FAST are discussed elsewhere. FAST and its variations follow a rule where an assumption is made that if intraabdominal free fluid can be identified in the undifferentiated abdominal trauma patient, the free fluid is assumed to be hemorrhagic and therefore an indication to proceed directly to the operating room for diagnostic and likely therapeutic laparotomy. [5]The reader will note that neither DPL nor FAST is capable of declaring the origin of the bleeding in question; the source of bleeding is to be determined by the operating surgeon at time of laparotomy in this evaluation model. A FAST exam, if negative, predicts that from an abdominal standpoint there is sufficent stability to undergo advanced imaging with computed tomography (CT) scanning. This is thought to be much more accurate regarding spleen trauma if intravenous contrast is used. The CT scan images of the traumatized spleen are then used to categorize the injury and predict clinical course and designate the best management plan for that specific injury pattern. [1]

Pertinent Studies and Ongoing Trials

The non-operative management of splenic trauma has seen recent refinements. There is ongoing pusuit of spleen salvage, and with interventional radiology embolization availability, higher grade spleen injuries are undergoing salvage rather than laparotomy removal[6][7]

Prognosis

Time is of the essence in the initial evaluation and management of the patient with splenic trauma. The time to laparotomy or endovascular management of high grade splenic trauma can influence outcomes, as increased intraabdominal blood loss can be predicted with delay in definitive management in the patient with high grade splenic trauma with active intraabdominal hemorrhage. Spleen salvage is preferred as the spleen is very important for optimized immune function. Spleen salvage has been suggested to be more likely at major medical centers with a full spectrum of services [8]. However, if a patient's initial presentation to the health care system is in a remote area with limited resources, the nearest available functional operating room staffed by a general surgeon may offer the best outcome, as prolonged tranport times can enhance blood loss and degrade predicted outcome. Some authors have suggested that delayed laparotomy may not offer benefit beyond nonoperative management if very significant delay in definitive management is unavoidable, but this likely needs validation before making assumptions regarding delayed management of spleen trauma in the austere environment [3]. Historically, splenectomy patients were at elevated risk of catastrophic septic events; immunization against S. pneumoniae, H. influenzae and N. menigiditis has suppressed the bulk of that risk [9], but vaccination compliance is non-uniform across populations, leading to variations in predicted infectious disease outcomes in splenectomy patients. [9]

Deterrence and Patient Education

Injury prevention in trauma patients in general is a focus of trauma care leadership. In developed nations, some authors suggest that there are potential improvements in infrastructure and general population education which could save many lives [10][11]. As of 2019 there has been increased interest in the United States regarding increased restrictions on firearm ownership as a method of trauma prevention, but this remains a highly politicized, highly emotionally charged topic with often acrimonious debate[12].

Pearls and Other Issues

Historically, patients with splenic injuries presenting to community hospitals have undergone splenectomy with general surgeons. Some have suggested a pattern of splenectomy rather than salvage being more likely at smaller hospitals than at large trauma centers. It has further been suggested that this may be related to the capacity in the larger centers to provide more intensive around-the-clock scrutiny of the patient, checking for any sign of deterioration as an indication that operative management had at that point become indicated. There is some anecdotal evidence that patients with low-grade splenic injuries are now transferred more frequently to tertiary/trauma centers, given a prediction of enhanced chances of spleen salvage at the larger facility. High-grade spleen injuries causing acute destabilizing blood loss are still thought best served by laparotomy by general surgery at the facility to which they initially present.

Enhancing Healthcare Team Outcomes

The collaboration between Surgery and Interventional Radiology has allowed patients to undergo spleen salvage who once would have been managed by laparotomy and splenectomy. As is noted above, spleen salvage has increasingly been the goal of management in splenic trauma, with a focus on promoting infectious disease outcomes and avoidance of the potential complications of the laparotomy procedure itself, which can occur even if laparotomy is done when indicated and under the best of preoperative circumstances, which is not necessarily always the case during emergency splenectomies. Multidisciplinary investigations are ongoing regarding which splenic trauma patients are best served by laparotomy, selective embolization by Interventional Radiology, or simply observing the patient until adequate healing had occurred to allow return to outpatient management. [13][14][15][16][15]

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Splenic Trauma - Questions

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A 16-year-old boy is seen in the emergency department after being kicked in the abdomen during a brawl at school. He is brought by his father, who says that he is fine and has no pain, but he wanted to visit the doctor to make sure it is not anything serious. The patient has no breathlessness or loss of consciousness. His vital signs include pulse rate: 100/minute, blood pressure: 110/70 mmHg, and temperature: 98.5 degrees Fahrenheit. On examination, he has slight tenderness in the upper abdomen. He is kept for observation, and his vitals are measured after half an hour. His blood pressure has dropped to 85/50 mmHg, and his pulse rate is 115/minute. He starts to complain of left shoulder tip pain. Which of the following is the most likely cause of his pain?

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A 17-year-old is punched in the stomach and develops a spleen laceration. He undergoes an urgent splenectomy, and the surgery is uneventful. There is no other source of injury. In the recovery room the patient is stable, but when he gets to the floor his blood pressure is 80/30 mm Hg and his pulse is 120. The drain site appears clean, but his abdomen is distended. Which of the following is most appropriate for the management of this patient?

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A 24-year-old male is brought to the emergency department after a road traffic accident with complaints of pain in the left upper abdomen. On examination, he has ecchymosis 5 X 6 cm on his left hypochondrium and reports pain in the left shoulder. His vitals include blood pressure: 80/50 mm of Hg, the pulse rate: 115/minute, and temperature: 98.2 degrees Fahrenheit. The patient remained vitally unstable despite resuscitative efforts and was ultimately taken to the emergency operating room. During the exploratory laparotomy blood vessels supplying the damaged organ are identified. The blood vessels that are injured are the main branches of the feeding artery to this organ with the feeding artery and hilar branches not affected. Which grade of injury of the organ involved is present in this patient?

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A 30-year-old male is brought to the emergency department after a car collision. He complains of pain in the upper abdomen and upper back on his left side. He has mild difficulty in breathing and appears pale. On examination, he is tender to touch in the left hypochondrium and has a laceration on the upper back on the left side. He also has bruises on his forehead and his left arm and forearm. His appears pale, and his vitals include pulse rate: 110/minute, blood pressure: 100/80 mm of Hg, and temperature: 98.3 degrees Fahrenheit. His hemoglobin is 5.8 g/dl. FAST ultrasound indicates free fluid in the left subdiaphragmatic region. He is transfused with two units of blood and then kept on a maintenance dose of ringer lactate. 2 hours later, his vitals include pulse rate: 100/minute, blood pressure: 105/80 mm of Hg, and temperature: 98.3 degrees Fahrenheit. Which of the following is the next best step in the management of this patient?

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A 16-year-old boy is brought to the emergency department following a motorcycle collision that occurred 1 hour back. He is breathless, pale, and has a bruise in his left hypochondrium extending to the back. He is conscious and oriented and has no allergies. His vitals include pulse rate: 112/minute, blood pressure: 78/50 mm of Hg, and temperature: 98.1 degrees Fahrenheit. The trauma team performs FAST ultrasound and diagnose free fluid in left subdiaphragmatic space. He is taken for emergency laparotomy. During the surgery, the patient has excessive generalized bleeding. Despite blood replacement, he remains hypotensive and his urine is dark. Which of the following is the next best step in the management of this patient?

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A young individual is kicked in the abdomen and is discovered to have a large splenic laceration. He undergoes an urgent splenectomy performed laparoscopically, and the surgery is uneventful. There is no other source of injury. In the recovery room, the patient is stable but when he gets to the intensive care unit a few hours later, his blood pressure is 65/30 mmHg, and pulse is 130 bpm. The surgical incision appears clean and the drainage site appears free of any blood. The only significant finding is a distended abdomen. The surgical resident states that the patient most likely has some residual carbon dioxide entrapped in the abdomen. What is the next step in his management?

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Asuquo ME,Etiuma AU,Bassey OO,Ugare G,Ngim O,Agbor C,Ikpeme A,Ndifon W, A Prospective Study of Blunt Abdominal Trauma at the University of Calabar Teaching Hospital, Nigeria. European journal of trauma and emergency surgery : official publication of the European Trauma Society. 2010 Apr; [PubMed]

Madhavan S,Taylor JS,Chandler JM,Staudenmayer KL,Chao SD, Firearm Legislation Stringency and Firearm-Related Fatalities among Children in the United States. Journal of the American College of Surgeons. 2019 Mar 27; [PubMed]

Tugnoli G,Bianchi E,Biscardi A,Coniglio C,Isceri S,Simonetti L,Gordini G,Di Saverio S, Nonoperative management of blunt splenic injury in adults: there is (still) a long way to go. The results of the Bologna-Maggiore Hospital trauma center experience and development of a clinical algorithm. Surgery today. 2015 Oct; [PubMed]

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